There's many a slip 'twixt implantation and the crib

Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I

Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two-part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.

Regulatory effect of daphnetin on the balance of Th17 and Treg cells in the peripheral blood mononuclear cells from patients with unexplained recurrent pregnancy loss

Introduction

There has a close relationship between the balance of T helper 17 (Th17) cells and Foxp3+ regulatory T cells (Treg) and unexplained recurrent pregnancy loss (URPL). The present study is to investigate the regulatory effect of daphnetin, which is extracted from Daphne odora Var, on the balance of Th17 and Treg cells in the peripheral blood mononuclear cells (PBMCs) from patients with URPL.

Material and methods

PBMCs were isolated from 35 pregnant women with URPL and 35 women with normal early pregnancies, respectively and treated with daphnetin for three days. Flow cytometry was performed to measure the proportions of Th17 and Treg cells. The level of expression of IL-6, TGF-β1 and IL-2 were detected using enzyme-linked immunosorbent assay (ELISA) and the level of expression of FoxP3, RORγt, signal transducers and activators of transcriotion 3 (STAT3) and STAT5 were detected by RT-PCR.

Results

The concentrations of Th17-type cytokines IL-2 were significantly decreased in the URPL group after treatment (p < 0.01). Treg-type cytokines such as TGF-β1 and IL-6 were significantly increased after treatment (p < 0.01). At the same time, daphnetin may induce a decrease in the ratio of RORγt to Foxp3 and a Treg cell bias, which would be beneficial for pregnancy maintenance. Futhermore the expression level of STAT3 were higher in the URPL patients whereas STAT5 were lower than those in the control subjects.

Conclusions

In conclusion, daphnetin may have regulatory effect on the balance of Th17 and Treg cells in the peripheral blood mononuclear cells from patients with URPL.

Effect of antithyroid antibodies on women with recurrent miscarriage: A meta-analysis

Problem

The effect of thyroid autoimmunity (TAI) on the prevalence of recurrent miscarriage (RM) is highly debatable. No meta‐analysis has been published in the past decade to investigate the impact of TAI on women with RM.

Method of Study

Systemic literature search was conducted on PubMed, Embase, Cochrane, and Web of Science databases. English language literatures published between 1993 and 2019 were selected. We assessed the relationship between the prevalence of RM and thyroid peroxidase antibodies (TPO‐Ab) or antithyroid antibodies (ATA) and evaluated the thyroid‐stimulating hormone (TSH) level in TPO‐Ab‐positive women with RM. We also observed the treatment effect with levothyroxine (LT4) for RM. Review Manager 5.3 software was used to obtain the pooled odds ratios (OR).

Results

Analysis of 22 eligible studies revealed significant association between TPO‐Ab and the prevalence of RM (OR = 1.85; 95% CI, 1.38 to 2.49; P < .001)(n ≥ 3), (OR = 1.82; 95% CI, 1.13 to 2.92; P = .01) (n ≥ 3). Women with ATA + had higher risk of RM (OR = 2.36; 95% CI, 1.71 to 3.25; P < .00001)(n ≥ 3), (OR = 2.34; 95% CI, 1.70 to 3.22; P < .00001)(n ≥ 2). RM women with TPO‐Ab had higher TSH level when compared with those negative for TPO‐Ab (random‐effect SMD = 0.60; 95% CI, 0.31 to 0.90; P < .0001). We also found beneficial effects of LT4 supplementation on the outcome of live birth rate (LBR) among pregnant women with TPO‐Ab (OR = 3.04; 95% CI, 0.69 to 13.36; P = .14).

Conclusion

The presence of serum antithyroid antibodies does harms to women and can even lead to recurrent miscarriage; LT4 treatment may have beneficial to RM women.

The inability of preovulatory ovarian scan to predict multifetal pregnancy occurrence in a follow-up of induction of ovulation with menotropins

OBJECTIVE

To establish the predictive role of preovulatory ovarian ultrasonography in the occurrence of multiple pregnancy after hMG and hCG treatment for anovulatory infertility.

DESIGN

Prospective.

SETTING

Outpatient Infertility Clinic.

PATIENTS

Ninety-five anovulatory women who conceived after gonadotropin therapy.

INTERVENTION

Induction of ovulation by hMG and hCG monitored by plasma E2 measurements and ovarian ultrasonography.

MAIN OUTCOME MEASURES

All follicles visualized on the day of hCG administration were recorded and divided into the following four groups: group I, 10 to 12 mm; group II, 13 to 15 mm; group III, 16 to 18 mm; and group IV, 19 mm and larger. The sonographic findings were statistically evaluated to 80 singletons and 45 multiple pregnancies.

RESULTS

No statistical correlation was found to exist between the number of follicles from the different groups and the number of fetuses.

CONCLUSIONS

The number and sizes of follicles visualized on the day of hCG administration have no predictive value regarding the occurrence of a multiple pregnancy.

Managing miscarriage. The need for more than medical mechanics

A compassionate physician recognizes the emotional as well as the physical needs of a woman who miscarries. The physical trauma is often short-lived, but the emotional aftermath may be prolonged. Dr Wells reviews the differential diagnosis and management of miscarriage and discusses the valuable role that a physician may take in alleviating the patient's feelings of guilt, grief, and frustration.

Conceptus viability, malformation, and suspect mutagens or teratogens in humans. The Yule-Simpson paradox and implications for inferences of causality in studies of mutagenicity or teratogenicity limited to human livebirths

If a genetic disorder or a congenital malformation is associated with embryonic or fetal death, then this may distort reported associations of environmental or biological factors with genetic and congenital disorders. We illustrate how such distortion may occur in humans as a manifestation of the Yule-Simpson (or Simpson) statistical paradox. We analyze the reported negative association of maternal smoking and Down syndrome in livebirths and demonstrate that under plausible conditions, valid negative associations both in livebirths and in embryonic or fetal deaths can occur, despite the fact that in all conceptuses there may be no association whatsoever. A similar analogous manifestation of the Yule-Simpson paradox may hold for positive associations. That is, positive relative risks may occur for an alleged mutagen or teratogen in separate studies both of livebirths, and of embryonic and fetal deaths, despite the absence of any effect in all conceptuses. These considerations illustrate the need for data on genetic disorders and malformations in embryonic and fetal deaths, and the need for a synthesis of such data with those from studies in livebirths before valid inferences may be made about mutagenic or teratogenic effects of environmental or biological factors.

Recurrent miscarriage

On epidemiological evidence, the definition of recurrent miscarriage should be three or more consecutive pregnancy losses. Data should be collected to 28 weeks' gestation but analysis up to 20-22 weeks' or 500 g fetal weight should also be possible. General practitioners and gynaecologists should do what they feel is suitable for couples whose history does not meet these criteria but a diagnosis of recurrent miscarriage should not be made. Women meeting the definition can be subdivided into primary and secondary groups, respectively consisting of those who have lost all previous pregnancies and those who have had one successful pregnancy followed by consecutive losses.